Growth

Important: Corrected age should be used at least until 24 to 36 months of age for premature infants born at < 37 weeks gestation.

Measuring growth: The growth of all term infants, both breastfed and non-breastfed, and preschoolers should be evaluated using Canadian growth charts from the 2006 World Health Organization Child Growth Standards (birth to 5 years) with measurement of recumbent length (birth to 2–3 years) or standing height (≥ 2 years), weight, head circumference (birth to 2 years) and calculation of BMI (2–5 years). WHO Growth Charts Adapted for Canada (DC)Growth Monitoring (CTFPHC)Optimal growth monitoring (CPS)

Breastfeeding

Breastfeeding: Exclusive breastfeeding is recommended for the first six months of life for healthy term infants. Introduction of solids should be led by the infant’s signs of readiness – a few weeks before to just after 6 months. Breast milk is the optimal food for infants, and breastfeeding (with complementary foods) may continue for up to two years and beyond unless contraindicated. Breastfeeding reduces gastrointestinal and respiratory infections and helps to protect against SIDS. Maternal support (both antepartum and postpartum) increases breastfeeding and prolongs its duration. Early and frequent mother-infant contact, rooming in, and banning handouts of free infant formula increase breastfeeding rates.

Vitamin D Supplementation

Vitamin D supplementation of 400 IU/day (800 IU/day in high-risk infants) is recommended for infants/children for as long as they are breastfed. Breastfeeding mothers should continue to take Vitamin D supplements for the duration of breastfeeding.Vitamin D supplementation (CPS)

Milk consumption range is consensus only & is provided as an approximate guide.

Soy-based formula is not recommended for routine use in term infants as an equivalent alternative to cow’s milk formula, or for cow milk protein allergy, and is contraindicated for preterm infants. Soy-based formulas (CPS)

Choking

Choking: Avoid hard, small and round, smooth and sticky solid foods until age 3 years. Encourage child to remain seated while eating and drinking. Use safe toys, follow minimum age recommendations, and remove loose parts and broken toys. Preventing choking and suffocation in children (CPS)

Pacifer Use

Pacifier use may decrease risk of SIDS and should not be discouraged in the 1st year of life after breastfeeding is well established, but should be restricted in children with chronic/recurrent otitis media. Pacifier recommendations (CPS)

Safe Sleeping

Sleep position, bed sharing and SIDS: Healthy infants should be positioned on their backs for sleep. Counsel parents on the dangers of other contributory causes of SIDS such as bed sharing, overheating, maternal smoking or second-hand smoke.

Positional plagiocephaly: While supine for sleep, the orientation of the infant’s head should be varied to prevent positional plagiocephaly. Sleep positioners should not be used. After umbilical cord stump has detached, infants should have supervised tummy time while awake.

Crib safety/Room sharing: Infants should sleep in a crib, cradle or bassinette, without soft objects, loose bedding and similar items that meet current 2016 Health Canada regulations in parents’ room for the first 6 months of life. Room sharing is protective against SIDS.

Swaddling: Proper swaddling of the infant for the first 2 months of life may promote longer sleep periods but could be associated with adverse events (hyperthermia, SIDS, or development of hip dysplasia) if misapplied. A swaddled infant must always be placed supine with free movement of hips and legs, and the head uncovered. Swaddling (AAP)

Falls

Falls: Assess home for hazards – never leave baby alone on change table or other high surface; use window guards and stair gates. Baby walkers are banned in Canada and should never be used. Ensure stability of furniture and TV. Advise against trampoline use at home. Trampoline use (CPS)

Crying

Crying: Excessive crying may be caused by behavioural or physical factors or be the upper limit of the normal spectrum. Caregiver frustration with infant crying can lead to child maltreatment/inflicted injury (head injury, fractures, bruising). The Period of Purple Crying. See Prevention of child maltreatment.

Night Waking

Night waking: occurs in 20% of infants and toddlers who do not require night feeding. Counselling around positive bedtime routines (including training the child to fall asleep alone), removing nighttime positive reinforcers, keeping morning awakening time consistent, and rewarding good sleep behaviour has been shown to reduce the prevalence of night waking, especially when this counselling begins in the first 3 weeks of life. Behaviour modification & sleep (MJA)Sleep problems & night wakings (Sleep)

Parenting/Discipline

Inform parents that warm, responsive, flexible & consistent discipline techniques are associated with positive child outcomes. Over reactive, inconsistent, cold & coercive techniques are associated with negative child outcomes. Use of any physical punishment including spanking should be discouraged in all ages. Effective discipline for children (CPS)

Refer parents of children at risk of, or showing signs of, behavioural or conduct problems to structured parenting programs which have been shown to increase positive parenting, improve child compliance, and reduce general behaviour problems. Access community resources to determine the most appropriate and available research-structured programs.
Parenting skills (EECD)

Parental Fatigue / Postpartum Depression

Maternal depression – Physicians should have a high awareness of maternal depression, which is a risk factor for the socio-emotional and cognitive development of children. Although less studied, paternal factors may compound the maternal-infant issues. Maternal depression and child development (CPS)

High Risk

Maternal depression: Physicians should have a high awareness of maternal depression, which is a risk factor for the socio-emotional and cognitive development of children. Although less studied, paternal factors may compound the maternal-infant issues. Maternal depression and child development (CPS)

Discuss with parents of preschoolers teaching names of genitalia, appropriate and inappropriate touch, and normal sexual behaviour for age.

Exposure to personal violence and other forms of violence has significant impact on physical and emotional well-being of children.

Assess home visit need: There is good evidence for home visiting by nurses during the perinatal period through infancy for first-time mothers of low socioeconomic status, single parents or teenaged parents to prevent physical abuse and/or neglect.

Complementary and alternative medicine (CAM)

Complementary and alternative medicine (CAM): Questions should be routinely asked on the use of homeopathy and other complementary and alternative medicine therapy or products, especially for children with chronic conditions.

Fever advice/thermometers

Fever advice/thermometers: Fever ≥ 38°C in an infant < 3 months needs urgent evaluation. Ibuprofen and acetaminophen are both effective antipyretics. Acetaminophen remains the first choice for antipyresis under 6 months of age; thereafter ibuprofen or acetaminophen may be used. Alternating acetaminophen with ibuprofen for fever control is not recommended in primary care settings as this may encourage fever phobia, and the potential risks of medication error outweigh measurable clinical benefit.Temperature measurement (CPS)

Vision Screening

Check Red Reflex for serious ocular diseases such as retinoblastoma and cataracts.

Corneal light reflex/cover–uncover test & inquiry for strabismus: With the child focusing on a light source, the light reflex on the cornea should be symmetrical. Each eye is then covered in turn, for 2–3 seconds, and then quickly uncovered. The test is abnormal if the uncovered eye “wanders” OR if the covered eye moves when uncovered.

Check visual acuity at age 3–5 years.

Corneal Light Reflex

Check Red Reflex for serious ocular diseases such as retinoblastoma and cataracts.

Corneal light reflex/cover–uncover test & inquiry for strabismus: With the child focusing on a light source, the light reflex on the cornea should be symmetrical. Each eye is then covered in turn, for 2–3 seconds, and then quickly uncovered. The test is abnormal if the uncovered eye “wanders” OR if the covered eye moves when uncovered.

Check visual acuity at age 3–5 years.

Hearing inquiry/screening

Hearing inquiry/screening – Any parental concerns about hearing acuity or language delay should prompt a rapid referral for hearing assessment. Formal audiology testing should be performed in all high-risk infants, including those with normal UNHS. Older children should be screened if clinically indicated.

Oral Health

Dental Cleaning: As excessive swallowing of toothpaste by young children may result in dental fluorosis, children under 3 years of age should have their teeth and gums brushed twice daily by an adult using either water (if low risk for tooth decay) or a rice grain sized portion of fluoridated toothpaste (if at caries risk). Children 3–6 years of age should be assisted during brushing and only use a small amount (e.g., pea-sized portion) of fluoridated toothpaste twice daily. Caregiver should brush child’s teeth until they develop the manual dexterity to do this alone, and should continue to intermittently supervise brushing after children assume independence. Begin flossing daily when teeth touch.

Caries risk factors include: child has caries or enamel defects, hygiene or diet is concerning, parent has caries, premature or LBW infant, or no water fluoridation.

To prevent early childhood caries: avoid juices/sweetened liquids and constant sipping of milk or natural juices in both bottle and cup.

Milk Consumption

Milk consumption range is consensus only & is provided as an approximate guide.

Dietary fat content: Restriction of dietary fat during the first 2 years is not recommended since it may compromise the intake of energy and essential fatty acids, required for growth and development. After 2 years, a gradual transition begins from a high fat milk diet to a lower fat milk diet, as per Canada’s Food Guide.

Injury Prevention

INJURY PREVENTION: In Canada, unintentional injuries are the leading cause of death in children and youth. Most of these preventable injuries are caused by motor vehicle collisions, drowning, choking, burns, poisoning, and falls. Unexplained injuries (e.g. fractures, bruising, burns) or injuries that do not fit the rationale provided or developmental stage raise concern for child maltreatment.

Oral Health

Dental Cleaning: As excessive swallowing of toothpaste by young children may result in dental fluorosis, children under 3 years of age should have their teeth and gums brushed twice daily by an adult using either water (if low risk for tooth decay) or a rice grain sized portion of fluoridated toothpaste (if at caries risk). Children 3–6 years of age should be assisted during brushing and only use a small amount (e.g., pea-sized portion) of fluoridated toothpaste twice daily. Caregiver should brush child’s teeth until they develop the manual dexterity to do this alone, and should continue to intermittently supervise brushing after children assume independence. Begin flossing daily when teeth touch.

Caries risk factors include: child has caries or enamel defects, hygiene or diet is concerning, parent has caries, premature or LBW infant, or no water fluoridation.

To prevent early childhood caries: avoid juices/sweetened liquids and constant sipping of milk or natural juices in both bottle and cup.

Development

Maneuvers are based on evidence-based literature on milestone acquisition. Evidence-based milestone ages (PCH). They are not a developmental screen, but rather an aid to developmental surveillance. They are set after the time of normal milestone acquisition. Thus, absence of any one or more items is considered a high-risk marker and indicates consideration for further developmental assessment, as does parental or caregiver concern about development at any stage.

Best Start website contains resources for maternal, newborn, and early child development

Hepatitis B vaccine (Hep B)

Hepatitis B vaccine can be routinely given to infants or preadolescents, depending on the provincial/territorial policy. The first dose can be given at 1 month, or at 2 months of age to fit more conveniently with other routine infant immunization visits. The second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose, but again may fit more conveniently into the 4- and 6-month immunization visits. Alternatively, Hep B can be administered as DTaP-IPV-Hib-HepB vaccine in infants, with the first dose at 2 months of age. A two-dose schedule for adolescents is an option.

For infants born to a mother with acute or chronic hepatitis B (HBsAg-positive), the first dose of Hep B vaccine should be given at birth (with Hepatitis B immune globulin, below) and repeat doses of vaccine at 1 and 6 months of age. Premature infants of birthweight less than 2,000 grams, born to HB- infected mothers, require four doses of HB vaccine at 0, 1, 2 and 6 months. The last dose should not be given before 6 months of age. Infants of HBsAg-positive mothers also require Hepatitis B immune globulin at birth and follow-up immune status at 9–12 months for HBV antibodies and HBsAg.

Infants with HBsAg-positive fathers, siblings or other household contacts require Hepatitis B vaccine at birth, and at 1 month, and 6 months of age.

Hepatitis B vaccine should also be given to all infants from high-risk groups, such as:

infants where at least one parent has emigrated from a country where Hepatitis B is endemic;

Provincial/territorial immunization schedules may differ based on funding differences. Provincial/territorial immunization schedules are available at the Public Health Agency of Canada.

Immunization pain reduction strategies: During vaccination, pain reduction strategies with good evidence include breastfeeding or use of sweet-tasting solutions, use of the least painful vaccine brand, and consideration of topical anaesthetics.
Reducing vaccine pain (CMAJ)